The Cardiac Care Unit of the Hamilton General Hospital is a busy 14-bed cardiac intensive care unit with high patient acuity and turnover. The trainee will be exposed to a large variety of both common and uncommon acute cardiac problems and will develop proficiency in their evaluation and management. Management of patients with acute myocardial infarction, congestive heart failure/pulmonary edema, cardiogenic shock, valvular heart disease, cardiac arrest, and a variety of arrhythmias will be emphasized. The trainee will be exposed to the medical, percutaneous and surgical approaches to the management of these acute problems and will be expected to develop a high degree of proficiency in understanding the indications, alternatives and complications of each potential therapy. The cardiology resident will be directly responsible for overseeing junior colleagues, including internal medicine, anaesthesia and emergency medicine residents. The development of supervisory skills is an important component of this rotation and in the final year of training all residents will serve as Junior Attending in the CCU.

CCU Goals & Objectives and ITERs

The Clinical Cardiology rotation is a ward-based rotation centered on the Cardiology Inpatient Units located at the Hamilton General Hospital and the Juravinski Hospital and Cancer Centre. The focus of the rotation is on the management of cardiac in-patients but will also include the provision of consultation services to the ER and other clinical services. Exposure will be obtained in all areas of clinical cardiology, including acute coronary syndromes, valvular heart disease, congestive heart failure, common arrhythmias, and perioperative cardiology. The cardiology resident will be expected to supervise junior colleagues rotating on the CTU, including internal medicine residents, clinical clerks, and elective medical students.

The Clinical Cardiology rotation at Juravinski Hospital is a combined low acuity CCU and consultation service for the JH. This rotation focuses on the management of patients in the CICU that include non-intubated cardiology patients and high-risk perioperative cardiovascular patients. The rotation has a strong General Cardiology consultation service that includes ER and in-patient consults for internal medicine, general surgery, orthopedic surgery and oncology. This rotation provides experience in the assessment of patients at risk of perioperative cardiovascular events undergoing non-cardiac surgery offering a specialized approach to risk stratification and disposition. Residents work hand in hand with the staff serving as junior attending and are expected to supervise Internal Medicine residents rotating in this service.

The Clinical Cardiology rotation at St. Joseph’s Hospital provides a unique patient population that includes nephrology, pulmonary hypertension and respiratory patients. This provides experience in the assessment and management of renal and pulmonary related cardiac pathology. There is also a growing perioperative service providing experience in assessment of patients at risk of perioperative cardiovascular events offering a specialized approach to the risk stratification and disposition. Lastly, the rotation allows for exposure to a large range of cardiovascular testing including transthoracic and transesophageal echocardiograms, ECGs, Holter monitors, exercise stress testing and nuclear perfusion imaging (both SPECT and PET). The absence of subspecialty residents provides an opportunity to participate in each modality along with patient care creating a true general cardiology experience.

The objective of the ambulatory clinics rotation is to provide the trainee with exposure to the out-patient management of cardiac disease. The clinics will provide an excellent opportunity to gain experience in the management of patients who transition from in-patient care to the ambulatory clinic and also provide the opportunity for longitudinal care of these patients; the trainee will obtain a better understanding of the natural history of common cardiac diseases and the impact of therapeutic interventions initiated in the clinic.

The rotation will be exclusively out-patient-based and will consist of two distinct components: 1) Longitudinal residents’ clinic, and 2) Person-based clinics.

Longitudinal Residents’ Clinic: Throughout the 3 years of the cardiology residency program, each resident will be assigned to a weekly general cardiology half-day clinic supervised by staff cardiologists. The resident however, will assume “ownership” of their patients and will provide longitudinal care throughout the year.

Person-based-Clinics: The trainee will also attend, on a regular basis, out-patient office-based clinics, under the supervision of a specific faculty member. Five half-day clinics (each with their own supervisor) will be attended each week. This will provide the trainee with exposure to a wide variety of sub-specialty clinics as well as exposing the trainee to a variety of practice styles. The trainee is allowed the flexibility of selecting the clinics he/she wants to attend based on their individual interests and can include not only General Cardiology Clinics but also specialized clinics such as Lipids, Hypertrophic Cardiomyopathy, Heart Function, Arrhythmia, Vascular and Adult Congenital clinics.

Clinical Goals and Objectives and ITERs

This is largely a clinic-based rotation where trainees are exposed to congenital heart disease from the pediatric and adult perspective. Residents attend 2.5 days of adult congenital clinics with three different staff cardiologists, as well as an additional half-day clinic devoted to the management of pregnant women with heart disease. Trainees will also attend 1.5 to 2 days of pediatric clinics with an exposure to fetal echocardiography and neonatology. Residents also round with the pediatric cardiologist on their in-patient service at least once a week and are "on call" to see new babies that are transported to MUMC with newly diagnosed, complex congenital lesions.

The rotation also offers exposure to case presentation and discussion by teleconference with Toronto General Hospital and Sick Kids hospital twice a week, with a once weekly didactic session covering a curriculum in CHD as well as various topics and research presentations by speakers throughout the year. The residents are required to present once in the 2-block period at pediatric cardiology rounds, usually involving a case or topic that has come up in their clinic time. We also have a monthly journal club where residents and staff will review and discuss recent and relevant publications.

This is a rotation with a fair amount of flexibility built into it, and allows a motivated resident with good organizational skills the opportunity to maximize his/her learning in the areas of congenital heart disease and pregnancy and heart disease. In addition to the above, residents have an opportunity to spend time in the cardio-pulmonary exercise lab with exposure to an exercise physiologist and cardiologist that spends 3 one hour sessions with them reviewing cardio-pulmonary exercise test interpretation.

The Cardiac Catheterization rotation is a lab-based rotation located in the Heart Investigation Unit (HIU) at the Hamilton General Hospital. As one of the highest-volume centres in the province with expertise in complex coronary interventions, structural heart disease, and cardiac hemodynamics, the HIU provides the resident exposure to a wide spectrum of invasive diagnostic and therapeutic interventions. The focus of the rotation is on the management of patients referred for cardiac catheterization for the investigation and treatment of a variety of cardiac disorders, including acute and chronic ischemic heart disease, valvular heart disease, cardiomyopathy, adult congenital heart disease, and pulmonary vascular disease. Emphasis is on the assessment of patients scheduled to undergo catheterization, the technical execution of the procedure, and the interpretation of the hemodynamic and angiographic data. The cardiology resident will be primarily involved in the assessment of patients undergoing left and/or right heart catheterization and will be encouraged to scrub in for all diagnostic studies; interventional procedures will be performed by the interventional cardiology fellow.

Exposure to one block of advanced imaging in cardiac CT and cardiac MR is incorporated in the rotation and occurs longitudinally with two days per week dedicated to the acquisition and interpretation of cardiac CT and MR images. This component of the rotation is based in the diagnostic imaging department at the Hamilton General Hospital and JHCC.

The trainee will be involved in performing a large number of diagnostic treadmill exercise tests on out-patients and in-patients with suspected coronary artery disease. The trainee will be exposed to the performance and interpretation of exercise and pharmacologic thallium and sestamibi perfusion imaging. Other procedures performed include radionuclide angiography and viability assessments with both perfusion and PET imaging. The trainee will be expected to learn indications, interpretation and clinical application of these tests.

Nuclear Goals and Objectives and ITERs

The trainee will be responsible for performing consultations on patients referred to the arrhythmia service. He/she will be exposed to a wide variety of rhythm disturbances including bradycardias, supraventricular dysrhythmias and ventricular dysrhythmias. This includes both inpatients and outpatients. Trainees will participate in the performance and interpretation of diagnostic invasive electrophysiologic studies, as well as therapeutic (ablative) procedures. Participation in non-invasive EP testing particularly in the autonomic lab is also fundamental to this rotation. The trainee will participate in permanent pacemaker and defibrillator implantation and follow-up. This rotation will also be used to read and review a large number of diagnostic 12 lead electrocardiograms, holters and to develop proficiency and expertise in this area.

Electrophysiology Goals and Objectives and ITERs

The cardiac trainee will be involved in the performance and interpretation of two dimensional and doppler echocardiographic examinations, out-patients, in-patients and emergency cases. The trainee will develop a high degree of proficiency in these skills. Advanced trainees will learn transesophageal echocardiography. There will also be opportunity to perform and learn echocardiography of congenital heart disease.

Echocardiography Goals and Objectives and ITERs

McMaster University is a leader in cardiovascular research, and research is considered an integral component of the development and training of adult cardiologists. A number of major projects are always ongoing and the resident has the opportunity to work on these from the “inside”. An ongoing commitment throughout the three years to research is expected, and dedicated blocks of time, with no other scheduled responsibilities, are scheduled in each year. Opportunities exist to develop and answer questions in both the basic sciences (with the Henderson Research Centre in Vascular Biology and Thrombosis) and the clinical/and population arena (with the Population Health Research Institute). It is expected that the trainee will identify a mentor in an area of his/her interest, will early in the course of their training develop a protocol, submit for internal and possibly external review, and execute the planned investigation. It is the goal of the program to have each trainee present at least one oral presentation at a national/international meeting, and first-author one peer reviewed paper, and one review article in their area of interest.

There is a weekly conference related to Resident Research. This consists of either attendance at Population health Research Institute Research rounds (about 15 times per year) or one of the following: 1. Resident presentation of on-going research,2. Journal club, 3. Faculty presentation of research methodology.

The electives rotation provides the flexibility for the trainee to tailor the residency program to meet their career goals: Trainees who wish to pursue further advanced clinical training in a cardiology sub-specialty often use this time to refine their skills in their sub-specialty of choice in preparation for advanced fellowship training. Trainees who wish to pursue a career in clinical or basic research can utilize this time for that purpose as well, while trainees who are interested in community cardiology can arrange electives in their community of choice. McMaster also offers international electives that can be arranged in collaboration with the Department of Medicine

An academic half-day occurs each Thursday. This includes a comprehensive, interactive, core curriculum which annually covers the topics outlined by the Royal College on Cardiology. These presentations are a collaboration between trainees and Cardiology teaching staff. An electronic library of these presentations is accumulated for future reference. Prior to the Core Curriculum, the half-day begins with Echo rounds. Once monthly radiology rounds and weekly physical exam sessions/hemodynamic sessions follow the core curriculum. Other weekly rounds include cardiac catheterization/cardiac surgery rounds, EKG rounds, Regional Cardiology rounds and Research rounds. Once monthly Journal review clubs are held.